Unfavorable Vascular Anatomy Is Associated with Increased Revascularization Time and Worse Outcome in Anterior Circulation Thrombectomy

Snelling, Brian; Sur, Samir; Shah, Sumedh S.; Chen, Stephanie; Menaker, Simon; McCarthy, David; Yavagal, Dileep R.; Peterson, Eric C.; Starke, Robert M.

doi:10.1016/j.wneu.2018.08.207

Cited by 71 publications

(78 citation statements)

References 21 publications

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“…Although the CCIA has never been specifically shown to have an influence on procedural times in mechanical thrombectomy, unfavorable arch types (type II or III) have been associated with more ischemic events and longer procedural times in patients undergoing carotid stent placement. [15][16][17][18] However, most of these studies found subjective associations primarily with arch type or, in 1 study, a composite "B.A.D. score" based on bovine variation, arotic arch type, and ICA dolichoarteriopathy.…”

Section: Discussionmentioning

confidence: 90%

“…score" based on bovine variation, arotic arch type, and ICA dolichoarteriopathy. 18 The 1 study to directly measure angulation did not use groin puncture to reperfusion time or clinical status as outcome measures but rather fluoroscopy time. 19 In addition, all of these studies were from a single institution, with only 1 study including both procedural time measures and clinical outcomes.…”

Section: Discussionmentioning

confidence: 99%

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Impact of Aortic Arch Anatomy on Technical Performance and Clinical Outcomes in Patients with Acute Ischemic Stroke

Knox¹,

Alexander

McCoy³

et al. 2020

AJNR Am J Neuroradiol

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BACKGROUND AND PURPOSE: Arterial access is a technical consideration of mechanical thrombectomy that may affect procedural time, but few studies exist detailing the relationship of anatomy to procedural times and patient outcomes. We sought to investigate the respective impact of aortic arch and carotid artery anatomy on endovascular procedural times in patients with large-vessel occlusion. MATERIALS AND METHODS: We retrospectively reviewed imaging and medical records of 207 patients from 2 academic institutions who underwent mechanical thrombectomy for anterior circulation large-vessel occlusion from January 2015 to July 2018. Preintervention CTAs were assessed to measure features of the aortic arch and ipsilateral great vessel anatomy. These included the cranial-to-caudal distance from the origin of the innominate artery to the top of the aortic arch and the takeoff angle of the respective great vessel from the arch. mRS scores were calculated from rehabilitation and other outpatient documentation. We performed bootstrap, stepwise regressions to model groin puncture to reperfusion time and binary mRS outcomes (good outcome, mRS # 2). RESULTS: From our linear regression for groin puncture to reperfusion time, we found a significant association of the great vessel takeoff angle (P 4 .002) and caudal distance from the origin of the innominate artery to the top of the aortic arch (P 4 .05). Regression analysis for the binary mRS revealed a significant association with groin puncture to reperfusion time (P , .001). CONCLUSIONS: These results demonstrate that patients with larger takeoff angles and extreme aortic arches have an association with longer procedural times as approached from transfemoral access routes. ABBREVIATIONS: CCA 4 common carotid artery; CCIA 4 the cranial-to-caudal distance from the origin of the innominate artery to the top of the aortic arch; GPRT 4 groin puncture to reperfusion time; HTN 4 hypertension; LVO 4 large-vessel occlusion I schemic stroke is the fifth leading cause of death and the leading cause of long-term disability in the United States. 1 Recent studies have established mechanical thrombectomy as the criterion standard of care for large-vessel occlusion over tPA alone. 2-5 These and other studies have demonstrated that reduced time between the onset of symptoms and reperfusion leads to better clinical outcomes. 6,7 That time interval comprises prehospital

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Section: Discussionmentioning

confidence: 90%

Section: Discussionmentioning

confidence: 99%

Impact of Aortic Arch Anatomy on Technical Performance and Clinical Outcomes in Patients with Acute Ischemic Stroke

Knox¹,

Alexander

McCoy³

et al. 2020

AJNR Am J Neuroradiol

View full text Add to dashboard Cite

show abstract

“…Despite the widening of the therapeutic window, faster reperfusion is critical for improved outcome 1. The BAD score (bovine arch, aortic arch, and internal carotid artery dolichoarteriopathy) has been described to predict longer times for reperfusion and worse outcomes, highlighting the deleterious impact of unfavorable arch/craniocervical vascular anatomy 6. In 61 patients who underwent transfemoral thrombectomy, age >75 years (OR 3.98, 95% CI 1.17 to 13.54) and high BAD score (OR 2.55, 95% CI 1.17 to 5.57) were significant predictors of puncture-to-reperfusion time >40 min 6…”

Section: Discussionmentioning

confidence: 99%

“…Preoperative planning can greatly affect procedural efficiency and, subsequently, clinical outcome 6. The transradial approach is a feasible alternative when unfavorable iliofemoral or aortic anatomy is noted 7.…”

Section: Discussionmentioning

confidence: 99%

Balloon anchoring technique forthrombectomyin hostile craniocervical arterial anatomy

Sharashidze

Nogueira

Grossberg

et al. 2020

J NeuroIntervent Surg

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BackgroundCraniocervical catheter access in large vessel occlusion acute ischemic strokes can be challenging in cases of unfavorable aortic arch/cervical vascular anatomy, leading to lower recanalization rates, increased procedural time and worse clinical outcomes. We aim to demonstrate the feasibility of the balloon-anchoring technique (BAT) that can be attempted before switching to alternative access sites.MethodsRetrospective review of prospectively collected information on 11 patients in which two variants of the BAT (proximal anchoring: balloon guide catheter (BGC) is inflated to provide support for distal access; distal anchoring: compliant balloon is inflated in an intracranial artery to allow advancement of the support system) were utilized to facilitate craniocervical access due to failure of conventional maneuvers.ResultsTen patients had anterior and one patient had posterior circulation large vessel occlusions. Mean age was 81 years and 81% were females. Type 3 arches were found in 82% and a 9 French balloon guide catheter was used in 82%. Proximal anchoring with BGC was used in four cases while distal anchoring was used in seven patients to allow access to the target vessel, avoiding the need to puncture alternative access sites. Successful reperfusion (modified treatment in cerebral ischemia 2b-3) was achieved in all cases and no complications were observed.ConclusionBAT is safe and feasible. It can be considered as a rescue maneuver in order to avoid switching to a different access during thrombectomy in individuals with unfavorable aortic arch/craniocervical anatomy.

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“…16 Many studies have reported that the longer the PT, the higher the risk of hemorrhagic transformation and the lower the odds of good clinical outcome. 13,[17][18][19][20][21] While a precise definition of refractory thrombectomy (RT) is lacking, it may be defined as a procedure that lasts too long, requires greater than three passes, or is not successful in obtaining an acceptable degree of reperfusion (TICI ≥2b). RT is a multifaceted problem comprising factors related to the patient (vascular anatomy and the underlying nature of the occlusive lesion including thrombus composition and the presence of atherosclerotic plaque) and the procedure (proper device and technique selection).…”

Section: Introductionmentioning

confidence: 99%

Unfavorable Vascular Anatomy during Endovascular Treatment of Stroke: Challenges and Bailout Strategies

et al. 2020

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The benefit of mechanical thrombectomy (MT) in acute ischemic stroke (AIS) due to large vessel intracranial occlusions is directly related to the technical success of the procedures in achieving fast and complete reperfusion. While a precise definition of refractoriness is lacking in the literature, it may be considered when there is reperfusion failure, long procedural times, or high number of passes with the MT devices. Detailed knowledge about the causes for refractory MT in AIS is limited; however, it is most likely a multifaceted problem including factors related to the vascular anatomy and the underlying nature of the occlusive lesion amongst other factors. We aim to review the impact of several key unfavorable anatomical factors that may be encountered during endovascular AIS treatment and discuss potential bail-out strategies to these challenging situations.

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Unfavorable Vascular Anatomy Is Associated with Increased Revascularization Time and Worse Outcome in Anterior Circulation Thrombectomy

Cited by 71 publications

References 21 publications

Impact of Aortic Arch Anatomy on Technical Performance and Clinical Outcomes in Patients with Acute Ischemic Stroke

Impact of Aortic Arch Anatomy on Technical Performance and Clinical Outcomes in Patients with Acute Ischemic Stroke

Balloon anchoring technique forthrombectomyin hostile craniocervical arterial anatomy

Unfavorable Vascular Anatomy during Endovascular Treatment of Stroke: Challenges and Bailout Strategies

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